ALERT TO HEALTHCARE WORKERS: EBOLA HAEMORRHAGIC FEVER OUTBREAK
IN GUINEA LIBERIA AND SIERRA LEONE, WEST AFRICA
Summary of current outbreak in Guinea, Liberia and Sierra Leone
The Ebola virus has been confirmed as the cause of an outbreak of haemorrhagic fever in
Guinea, West Africa. This is the first recorded outbreak of Ebola haemorrhagic fever (EHF)
in Guinea, where Lassa fever is commonly reported. The most recent outbreaks of EHF
were reported from the Democratic Republic of Congo and Uganda in 2012.
This outbreak is reported to have started in early February 2014. According to the World
Health Organization (WHO), as of 28March 2014 the total number of cases in the ongoing
EHF outbreak in Guinea has increased to 112, including 70 deaths(CFR=62.5%). New
suspected cases have been reported from Conakry (n=4), Gueckedou (n=4), Macenta (n=1)
and Dabola (n=1) prefectures. The date of hospital admission of the most recent suspected
case is 28 March 2014. All age groups have been affected, but most of the cases are adults
aged 15-59 years. To date, all cases have been in persons or healthcare workers attending
to cases or attending burials from three districts (Gueckedou, Macenta and Kissidougo) in
the forested rural areas of south eastern Guinea, and also the capital city Conakry (Figure).
Two of thenew suspected cases are healthcare workers, indicating the need to further
strengthen health facility-based infection prevention and control. Active contact tracing is
proceeding.
To date,24 clinical samples from Guinea have tested positive by PCR for the Ebola virus in
samples from cases in Conakry, Gueckedou and Macent. Laboratory studies demonstrated
that Zaire Ebola virus is the virus responsible for the outbreak. Ebola Zaire virus is highly
lethal with CFR of up to 90% reported in previous outbreaks.
In addition, Liberia has reported two laboratory-confirmed cases in persons who had
travelled to Guinea. To date, Sierra Leone has reported two suspected cases, both of whom
died. All of the confirmed and suspected cases reported by Liberia and Sierra Leone had
travelled to Guinea before illness onset. Investigations into these suspected cases are
ongoing.
In accordance with the International Health Regulations (IHR 2005), the Ministries of Health
of Guinea, Sierra Leone and Liberia together with WHO and other response partners are
implementing a coordinated response to the outbreak. WHO and response partners are
continuing to support the outbreak response through mobilising international expertise
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(clinical care, infection prevention and control including isolation services, surveillance and
epidemiology, laboratory diagnosis and reference, logistics and social mobilisation).
Ebola haemorrhagic fever: the basics
The ecology of the Ebola virus is not completely understood. The current prevailing
hypothesis is that the virus is introduced into the human population through close contact
with infected animals (including chimpanzees, gorillas, bats, monkeys, forest antelope and
porcupines). The likely reservoir of the virus includes specific species of arboreal bats, and
contact with these animals and/or their excretions/secretions may also result in transmission
of the virus to humans. Human-to-human transmission often occurs, and is a predominant
feature of outbreaks. The disease can be spread from person to person through contact with
blood, secretions, organs, or other body fluids. Ebola haemorrhagic fever outbreaks have
been reported most commonly from the Democratic Republic of Congo, Uganda, South
Sudan, Congo and Gabon.
The incubation period of the disease is 2 - 21 days. An acute onset of prodromal symptoms
which include fever, malaise, myalgia, diarrhoea, vomiting and abdominal pain is usual,
followed by progressive multisystem disease with bleeding as a cardinal feature in the
majority of patients. Currently, there is no known specific treatment or preventative vaccine
for this highly contagious virus.
Risk of imported Ebola haemorrhagic fever cases
Since the current outbreak is reported in predominantly rural areas which are not frequented
by many tourists or travellers, the risk of Ebola haemorrhagic fever cases being imported
into South Africa is low. However, healthcare or international agency workers etc. involved in
the outbreak response may travel to and present in South Africa for medical care, and a high
index of suspicion is important for such cases. A detailed history regarding travel and level of
contact with suspected/confirmed Ebola haemorrhagic fever cases is extremely important.
Recommendations for travel to/from Guinea and West Africa
The World Health Organization (WHO) does not recommend that any travel or trade
restrictions be applied to Guinea, Liberia or Sierra Leone based on the current information
available for this event. There are no special precautions or directives for commercial flights,
passengers or crew departing on flights bound for or returning to Guinea, Liberia or Sierra
Leone. The regulations for evidence of a valid yellow fever vaccination certificate apply.
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Any ill persons reported on flights from Guinea, Liberia or Sierra Leone and neighbouring
countries will need to be evaluated by the relevant Port Health officials. All requests for
medical evacuation of persons from Guinea, Liberia or Sierra Leone with febrile illness or
suspected infectious disease will need careful evaluation by the Port Health officials.
While the risk of introduction of Ebola virus into South Africa is considered low, we strongly
recommend that surveillance for viral haemorrhagic fevers (and at present, particularly Ebola
haemorrhagic fever), be strengthened. This should be done primarily through Port Health
services, but it is also extremely important that public and private practitioners are on the
alert for any ill persons that have travelled to viral haemorrhagic fever risk areas. There
needs to be a high index of suspicion for EHF in health workers from the affected region with
unexplained fever.
Evaluation of illness in travellers from Guinea and West Africa
It is critical to maintain a very high index of suspicion for common causes of febrile illness in
persons who have travelled to Guinea and surrounding countries, including: malaria, dengue
fever, Lassa fever and other endemic diseases (e.g. typhoid fever). These may be severe
and life-threatening, and healthcare workers are urged to do appropriate tests and institute
appropriate therapy as a matter of urgency. Malaria is the most likely cause of an acute
febrile in returning travellers from most African countries and has to be prioritised for testing.
However, Lassa fever is endemic in certain West African countries, including Nigeria, Sierra
Leone, Guinea and Liberia - and needs to be considered in the differential diagnosis for any
traveller from these countries who has unexplained febrile illness and has visited rural areas.
Lassa fever virus is transmitted to humans through direct contact with urine and droppings of
infected multi-mammate rats, which contaminate the environment and food items.
Transmission can also occur through the inhalation of aerosolised infected rodent excreta.
Person-to-person transmission is also important, being common in both village and
healthcare settings, and occurs through direct contact with blood, tissue, secretions or
excretions of an infected person; therefore, VHF isolation precautions are recommended for
nursing patients with Lassa fever. The incubation period is 1-3 weeks; symptoms include
fever, retrosternal pain, sore throat, back pain, cough, abdominal pain, vomiting, diarrhoea,
facial swelling and mucosal bleeding. Mortality rates approach 20%, with pregnant women in
their third trimester being at highest risk for severe disease and death. Given that the
incubation periods and clinical presentations of Lassa fever and Ebola haemorrhagic fever
may overlap, both diseases must be excluded in persons who have a suggestive travel
history and present with a febrile illness.
Suspected Ebola haemorrhagic fever case definition and laboratory testing
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The case definition for suspected Ebola haemorrhagic fever is as follows:
Any person* presenting with an acute onset of fever that has:

Visited or been resident in Guinea, Liberia or Sierra Leone in the 21 days prior to onset
of illness

AND
had direct contact or cared for suspected/confirmed Ebola haemorrhagic fever cases in
the 21 days prior to onset of illness, or been hospitalised in Guinea
OR
Has unexplained multisystem illness that is malaria-negative
*Healthcare workers in particular are at high risk
Testing for viral haemorrhagic fever viruses (including Ebola virus) in South Africa is only
available at the NICD.
Ebola haemorrhagic fever testing is neither warranted nor useful for persons that are not
suffering from a clinical illness compatible with Ebola haemorrhagic fever, even in the event
of compatible travel histories. The tests cannot be used to determine if the patient has been
exposed to the virus and may develop the disease later.
Requests for testing (with a detailed clinical, travel and exposure history) should be directed
to the NICD Hotline at 082 883 9920 (a 24-hour service, for healthcare professionals only).
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Figure.Geographic distribution of Ebola haemorrhagic fever in Guinea and Liberia, as at 28
March 2014.World Health Organization Regional Office for Africa.
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